Update anaesthesia 2010

International guidelines for the management of severe sepsis and septic shock 15 do not specifically recommend the use of HA for volume replacement for haemodynamic stabilization in this setting. Burns are seen as a potential indication for administration of HA, but not in the first 24 h after burn trauma. In trauma patients with severe hypovolaemia, rapid correction using HA is not possible as it is supplied in glass bottles and high-volume pressure infusion is not possible.

The use of HA to correct hypovolaemia in trauma patients has not been shown to have a significant benefit in survival when compared with other plasma substitutes. There are no controlled studies on volume substitution to correct hypovolaemia in early pregnancy. The use of HA for this purpose has also not been established in controlled clinical trials. Animal reproduction studies have not been conducted with HA [e. It is not known whether albumin solutions can cause fetal harm when given to a pregnant woman or can affect reproductive capacity.

However, severe hypovolaemia during the first months of pregnancy e. Nevertheless, HA should be given to a pregnant woman only if really needed. Correction of hypovolaemia in patients undergoing major liver surgery or liver transplantation has long been considered an indication for using HA. However, such patients have also successfully been treated with synthetic colloids. There are no large-scale prospective trials. The use of HA has long been regarded as the treatment of choice for volume substitution in young children.

There are only a few reports of effects on haemodynamics, organ function or outcome of the use of HA in neonates, premature infants, and children under the age of 12 months. Even in high-risk neonates, overall survival was not increased after HA adminstration. Shorter hospital stay and lower costs were shown when using hyperoncotic HA for correction of hypovolaemia patients with liver disease.

Two studies, which were more than 15 yr old, reported reduced disability after using hyperoncotic albumin in brain injury. Hypoalbuminaemia has been shown to be associated with poor clinical outcome. In human plasma, albumin concentration ranges around 3. The main factor governing production of albumin is COP in the extravascular space of the liver. Albumin synthesis is also reduced under these circumstances, but with a half-life of around 20 days, this cannot explain the rapid decrease in serum albumin concentration in critical illness.

The most significant cause of the reduced albumin level is apparent redistribution e. In patients with sepsis, an increased vascular permeability capillary leak plays an important role in developing hypoalbuminaemia by the shift of albumin from the intravascular to the interstitial compartment.

After infusion of HA, its distribution within the extravascular compartment is complete after 7—10 days. In this setting, capillary leak of albumin can increase to 13 times its normal level. Hypoalbuminaemia is a predictor of increased mortality and morbidity in surgical or ICU patients. Enteral feeding was also better tolerated, oxygenation improved in acute pulmonary failure and a less positive fluid balance was achieved.

There is evidence that correction of hypoalbuminaemia does not beneficially influence outcome. In a prospective, randomized study of patients with hypoalbuminaemia after gastrointestinal surgery, no benefits of HA were shown.

The authors concluded that HA administration in the early stage of postoperative hypoalbuminaemia did not benefit clinical outcomes. A cohort, multicentre, observational study of ICU patients showed that HA administration was associated with decreased survival in these patients.

Its composition of amino acids which has a low ratio of some essential amino acids tryptophan, methionine, and isoleucine and its long biological half-life of around 19—21 days makes HA unsuitable for use in parenteral nutrition. In cirrhotic patients with ascites, there is some evidence that HA leads to a reduction in morbidity and mortality. The decision on need for volume replacement or use of HA depends on the degree of severity of liver cirrhosis and the extent of the haemodynamic, hormonal, and immunological deficits.

However, the control group in this study did not receive adequately controlled fluid replacement and thus remained hypovolaemic. In the majority of the trials on the treatment of HRS, vasoconstrictors were used in combination with HA. However, this trial has a methodological flaw in that after the enrolment of 13 patients the protocol terlipressin plus albumin was modified. Paracentesis for drainage of ascites without volume compensation is associated with the risk of developing PPS.

The incidence of PPS is associated with a considerably higher risk of developing renal failure and an overall increased mortality. There were no significant differences between the individual groups regarding mortality and incidence of clinical complications.

The use of HA over a long time-period in this setting may be of advantage. A randomized, unblinded, non-placebo controlled clinical trial of patients with liver cirrhosis and first onset ascites compared a standard therapy without other colloid volume replacement with and without administration of HA 25 g per week in the first year and 25 g every 2 weeks thereafter.

In nephrotic syndrome, albumin is lost via the kidneys. Compensation of the resulting hypoalbuminaemia is not useful as most of it is quickly eliminated again. Albumin serves as a transport protein for many substances e. Since an increase in the free fraction of a substance is most often followed by a more rapid metabolism or an increased elimination of this substance, no critical increase in the concentration of the free substance in plasma is to be anticipated in the case of low levels of albumin.

There is no risk of acute toxic effects resulting from hypoalbuminaemia because of rapid migration of the unbound fraction of drugs from the intravascular to the extravascular space, so that a low-level balance is reached.

Albumin acts as a free radical scavenger and is able to bind toxic substances e. Therefore, there could be an indication for HA in patients with sepsis because toxic oxygen radicals play a role in pathogenesis and maintenance of sepsis, 51 and have a beneficial effect in these patients. However, to date, there are no confirmed data on the benefit of HA therapy regarding morbidity or mortality in humans.

In addition, it is uncertain whether HA preparations currently commercially available have the same radical scavenger properties as natural albumin or whether they are altered by the manufacturing process. No substance-specific clinically relevant alterations in the coagulation capacity nor alterations in organ function due to iso-oncotic HA therapy have been reported. Adverse effects that were directly associated with albumin were an extremely rare event during this observation period.

There are, however, more recent reports that the use of hyperoncotic HA is associated with significant damage for some patients. A post hoc follow-up analysis of data from the SAFE study showed a significantly increased mortality for patients with traumatic brain injury treated with HA as opposed to the non-albumin group. The only substance-specific contraindication for albumin is an established allergy against HA, or rather against the solubilizing agent. As any HA infusion e.

Particular caution is required in patients with severely restricted cardiac function. As is true for all volume substitutes, congestive heart failure with pulmonary oedema and hypocoagulopathy due to dilution are contraindications for using HA. In conclusion, the widespread use of HA worldwide appears to be based on strong views rather than controlled study results. The wider use of HA should not be based on presumed potential benefits in selected patient groups. It has been shown that the most common indications for using HA were hypotension in haemodialysis As mortality may not be the ideal endpoint for assessing the value of HA, morbidity appears to be of increasing interest.

A meta-analysis of randomized, controlled trials showed that except in patients with ascites, the use of HA was not associated with significantly improved morbidity Fig.

Effects of use of HA on risk ratio RR and confidence interval CI for morbidity in different clinical settings data taken from Vincent and colleagues. In times of increasing cost consciousness and cost containment, costs of HA are notable and ranging from two- to fold of that of synthetic colloids. In a prospective cohort study of ICU patients, the influence of more restrictive use of HA on mortality and cost savings was assessed.

It is apparent that we need more strict recommendations and guidelines to limit non-justified use of HA. These savings can be better used for other cost-intensive strategies in the management of the critically ill. Per cent of ICU costs by fiscal year by albumin use data taken from Weber and colleagues. This article was not supported by a pharmaceutical company. The author has previously received sponsorship honorarium, study support from B. Google Scholar. Google Preview.

He recommends a restrictive use of this blood product, citing limited availability and high cost as major drawbacks to its use. This may represent a Teutonic viewpoint, but not so an international one. There is also a need for further studies on mechanism of action, assessing whether the additive effect of adjuncts is local or merely systemic. Assessing not only the early first hour postoperative pain effects but also the overall recovery and the effects for up to at least a week after surgery using validated recovery tools such as the Postoperative Quality of Recovery scale 57 are warranted.

Fischer and Bosch did indeed address this in a recent paper Does regional anaesthesia improve outcome after surgery? An update found evidence that upper extremity blocks provide effective intraoperative and early postoperative analgesia, reducing opioid consumption in the first 24 hours, but may cause rebound pain 59 , The continuous perineural infusion is a feasible alternative, providing effective analgesia and improving quality of recovery, sleep quality, and patient satisfaction.

Upper extremity surgery can be performed safely in peripheral block as sole anaesthesia or in combination with sedation and general anaesthesia as needed. Planning and proper logistics are of importance when implementing regional anaesthesia. Factors of importance include time to onset of block, duration of surgical anaesthesia, and duration of postoperative analgesia. The use of nerve stimulation or even more ultrasound guidance improves the success rate of the block and reduces the risk of side effects.

Use of long-acting local anaesthetic solution delays onset but prolongs duration of effective anaesthesia. Addition of adjuncts prolongs the duration of postoperative analgesia, but further studies are warranted in order to better document safety and whether systemic administration is equally effective as compared to perineural administration.

Perineural catheters and continuous infusion are also an effective alternative to prolong the analgesic effects. F Faculty Reviews are commissioned from members of the prestigious F Faculty and are edited as a service to readers.

In order to make these reviews as comprehensive and accessible as possible, the referees provide input before publication and only the final, revised version is published. The referees who approved the final version are listed with their names and affiliations but without their reports on earlier versions any comments will already have been addressed in the published version.

National Center for Biotechnology Information , U. Journal List FRes v. Version 1. Published online May Jakobsson a, 4. Jan G. Author information Article notes Copyright and License information Disclaimer. Competing interests: The authors declare that they have no competing interests.

Accepted May This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. This article has been cited by other articles in PMC.

Keywords: upper extremity block, peripheral blocks, ultra-sound guided, anaesthesia, interscalene, supraclavicular, infraclavicular, axillary plexus. Introduction Peripheral blocks have been part of anaesthetic techniques used for upper extremity surgery for decades.

The upper extremity blocks may be divided into the following 13 : Interscalene, shoulder surgery Supraclavicular, the entire arm Infraclavicular, the elbow and below Axillar plexus, from below the elbow The aim of the present paper is to provide an update and overview of the clinical usage of upper extremity nerve blocks, how analgesic effect can be prolonged, and how safety can possibly be improved, strengthening the benefit vs.

Efficacy and outcome Interscalene block Today, the interscalene block is well established for intraoperative as well as postoperative pain management associated with shoulder surgery.

The infraclavicular plexus block There is one recent meta-analysis assessing the available evidence on the infraclavicular block technique for perioperative use.

The axillary plexus block Chin et al. Risk and side effects The upper extremity block may cause side effects, such as nerve damage, intravascular injection causing local anaesthesia toxicity, diaphragm dysfunction, and pneumothorax.

Techniques in order to facilitate block quality and duration The single-shot upper extremity blocks have effective anaesthesia duration of hours when performed with a long-lasting local anaesthetic bupivacaine, levobupivacaine, or ropivacaine.

Clonidine Alphaagonists have been added to upper extremity blocks for decades. Dexmedetomidine Swami et al. Dexamethasone In , Choi et al. Perineural catheters An alternative option is to use an indwelling perineural catheter for continuous administration of local anaesthetic with or without adjuncts.

Future perspectives Upper extremity blocks provide effective analgesia for the duration of the local anaesthetic used.

Key message Upper extremity surgery can be performed safely in peripheral block as sole anaesthesia or in combination with sedation and general anaesthesia as needed.

Training and skill in the regional anaesthesia technique must be secured. Notes [version 1; referees: 3 approved]. Funding Statement The author s declared that no grants were involved in supporting this work. References 1. Bier's Block — Reg Anesth Pain Med. J Clin Anesth. Benhamou D: Axillary plexus block using multiple nerve stimulation: a European view. Cochrane Database Syst Rev. J Anaesthesiol Clin Pharmacol. Guay J: [The neurostimulator for brachial plexus blockade by the axillary approach: a metaanalysis on its efficacy to increase the success rate].

Ann Fr Anesth Reanim. A Systematic Review and Meta-Analysis. Anesth Analg. Ullah H, Samad K, Khan FA: Continuous interscalene brachial plexus block versus parenteral analgesia for postoperative pain relief after major shoulder surgery.

Anaesthesiol Intensive Ther. Bone Joint J. Can J Anaesth. Chin KJ, Alakkad H, Cubillos JE: Single, double or multiple-injection techniques for non-ultrasound guided axillary brachial plexus block in adults undergoing surgery of the lower arm. Indian J Anaesth. Ultrasound versus nerve stimulation]. Abell DJ, Barrington MJ: Pneumothorax after ultrasound-guided supraclavicular block: presenting features, risk, and related training.

J Shoulder Elbow Surg. Br J Anaesth. PLoS One. Am J Health Syst Pharm. Singelyn FJ, Gouverneur JM, Robert A: A minimum dose of clonidine added to mepivacaine prolongs the duration of anesthesia and analgesia after axillary brachial plexus block. A qualitative systematic review of the literature. Abdallah FW, Brull R: Facilitatory effects of perineural dexmedetomidine on neuraxial and peripheral nerve block: a systematic review and meta-analysis.

A systematic review and meta-analysis. Choi S, Rodseth R, McCartney CJ: Effects of dexamethasone as a local anaesthetic adjuvant for brachial plexus block: a systematic review and meta-analysis of randomized trials.

Pain Res Treat. Huynh TM, Marret E, Bonnet F: Combination of dexamethasone and local anaesthetic solution in peripheral nerve blocks: A meta-analysis of randomised controlled trials.

Eur J Anaesthesiol. J Anesth. Expert Rev Clin Pharmacol. A test dose of epinephrine 0. Warning symptoms are cardiac frequency modification an increase or decrease by 10 beats per minute , increased in blood pressure up to 15mmHg , or T-wave amplitude change in Figure 7. Figures 8a and 8b.

Figure 6A and B. Table 2. Maximal allowable doses of local anaesthestic agents Plain local With epinephrine anaesthetic mg.

Full dose The volume of caudally injected LA determines the spread of the block and this must be adapted to surgical procedure Table 1. Analgesic spread will be two dermatomes higher on the down positioned side at the time of puncture.

Injected volume must not exceed 1. T-wave amplitude change after intravascular injection of a local anaesthetic agent Table 1. Spread of block as a function of caudally injected local anaesthetic volume18 Volume ml. Bupivacaine meets these criteria.

They may also confer a more favorable differential block less motor block for the same analgesic power and the 2. Four to six hours analgesia is usually achieved with minimal motor block. Hemodynamic effects of CA are weak or absent in children, so intravenous fluid preloading or vasoconstrictive drugs are unnecessary. Thisismorelikelyiftheneedleisadvancedexcessivelyinthe sacralcanalwhensubarachnoidinjectionoflocalanaestheticagentmay cause extensive spinal anaesthesia.

Under general anaesthesia this should be suspected if non-reactive mydriasis pupillary dilation is observed. Preventative measures are use of a test dose, cessation of injection if resistance is felt and slow injection under hemodynamic and ECG monitoring. Sacral perforation can lead to pelvic organ damage e. Theoretical risk of respiratory depression with opioids mandates adequate postoperative monitoring. Some cases of respiratory depression have been reported with caudal clonidine in neonates.

Despite being more complex to learn, alternative peripheral regional anaesthesia techniques are gaining popularity and may begin to replace caudal anaesthesia as a popular choice. Update in Anaesthesia The caudal canal in children: a study using magnetic resonance imaging. Paediatr Anaesth ; Dalens B, Hasnaoui A.

Caudal anesthesia in pediatric surgery: success rate and adverse effects in consecutive patients. Anesth analg ; Br J Anaesth ; Confirmation of caudal needle placement using nerve stimulation. Anesthesiology ; Determining the accuracy of caudal needle placement in children: a comparison of the swoosh test and ultrasonography. Caudal injectate can be reliably imaged using portable ultrasound - a preliminary result. Paediatr anaesth ; Ultrasound and caudal blocks in children.

Paediatr Anaesth ; correspondence. Caudal analgesia and anesthesia techniques in children. Curr Op Anesthesiol ; Bacterial colonisation and infectious rate of continuous epidural catheters in children. Anesth Analg ; Thoracic epidural catheters placed by the caudal route in infants: the importance of radiographic confirmation.

Subcutaneous tunneling of caudal catheters reduces the rate of bacterial colonization to that of lumbar epidural catheters. Thoracic and lumbar epidural analgesia via the caudal approach using electrical stimulation guidance in pediatric patients: a review of patients. Detection of epidural catheters with ultrasound in children. Epidural analgesia for major neonatal surgery.

Paediatr Anaesth ; 8: Epidemiology and morbidity of regional anesthesia in children: a one-year prospective survey of the French-language society of pediatric anesthesiologists. Cardiovascular criteria for epidural test dosing in sevoflurane- and halothane-anesthetized children. Tobias JD. Caudal epidural block: a review of test dosing and recognition injection in children. Armitage EN. Local anaesthetic techniques for prevention of postoperative pain.

Acta Anaesthesiol Scand ;